﻿<%@page import="com.cchr.acms.model.Action"%>
<%@page import="com.cchr.acms.model.AbuseType"%>
<%@page import="com.cchr.acms.util.HtmlComponentUtil.SelectOption"%>
<%@page import="java.util.List"%>
<%@page import="com.cchr.acms.util.HtmlComponentUtil"%>
<%@ page language="java" contentType="text/html; charset=UTF-8"   pageEncoding="UTF-8"%>
<%@ taglib prefix="c" uri="http://java.sun.com/jsp/jstl/core"%>
<%@ taglib uri="http://java.sun.com/jsp/jstl/fmt" prefix="fmt" %>
<%
	String contextPath = request.getContextPath();
%>
<!DOCTYPE html>
<!--[if IE 8]>         <html class="ie8"> <![endif]-->
<!--[if IE 9]>         <html class="ie9 gt-ie8"> <![endif]-->
<!--[if gt IE 9]><!--> <html class="gt-ie8 gt-ie9 not-ie"> <!--<![endif]-->
<head>
	<meta charset="utf-8">
	<meta http-equiv="X-UA-Compatible" content="IE=edge,chrome=1">
	<title>Report Psychiatric Abuse</title>
	<meta name="viewport" content="width=device-width, initial-scale=1.0, user-scalable=no, minimum-scale=1.0, maximum-scale=1.0">

	<!-- Open Sans font from Google CDN -->
	<link href="http://fonts.googleapis.com/css?family=Open+Sans:300italic,400italic,600italic,700italic,400,600,700,300&subset=latin" rel="stylesheet" type="text/css">

	<!-- Pixel Admin's stylesheets -->
	<link href="<%=contextPath%>/assets/stylesheets/bootstrap.min.css" rel="stylesheet" type="text/css">
	<link href="<%=contextPath%>/assets/stylesheets/pixel-admin.min.css" rel="stylesheet" type="text/css">
	<link href="<%=contextPath%>/assets/stylesheets/pages.min.css" rel="stylesheet" type="text/css">
	<link href="<%=contextPath%>/assets/stylesheets/rtl.min.css" rel="stylesheet" type="text/css">
	<link href="<%=contextPath%>/assets/stylesheets/themes.min.css" rel="stylesheet" type="text/css">
	<link href="<%=contextPath%>/assets/stylesheets/select2.min.css" rel="stylesheet" type="text/css">

	<!--[if lt IE 9]>
		<script src="<%=contextPath%>/assets/javascripts/ie.min.js"></script>
	<![endif]-->

</head>
<style type="text/css">
.page-signup-alt .panel{
width:40%;
margin:0 auto;
padding:27px}
</style>


<!-- 1. $BODY ======================================================================================
	
	Body

	Classes:
	* 'theme-{THEME NAME}'
	* 'right-to-left'     - Sets text direction to right-to-left
-->
<body class="theme-default page-signup-alt">
	<!-- Form -->
	<form class="panel form-horizontal" id="jq-validation-form" method="POST" style="width:1050px">
		<a href="https://www.cchrint.org/">
			<img src="<%=contextPath%>/assets/images/case/create_header.png"/>
		</a>
		<div class="row">
			<div class="col-sm-4">
				<div class="form-group no-margin-hr">
					<label class="control-label"><h1 class="form-header">Today's Date:</h1></label>
					<div class="input-group date bs-datepicker-component">
						<input type="text" class="form-control" name="createDate"><span class="input-group-addon"><i class="fa fa-calendar"></i></span>
					</div>
				</div>
			</div>	
		</div>
		
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label"><h1 class="form-header">Information on the Person Abused:</h1></label>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-4">
				<div class="form-group no-margin-hr">
					<label class="control-label">First Name</label>
					<input type="text" class="form-control" name="abusedPerson.firstName"  placeholder="First Name">
				</div>
			</div>
			<div class="col-sm-4">
				<div class="form-group no-margin-hr">
					<label class="control-label">Middle Name</label>
					<input type="text" class="form-control" name="abusedPerson.middleName" placeholder="Middle Name">
				</div>
			</div>
			<div class="col-sm-4">
				<div class="form-group no-margin-hr">
					<label class="control-label">Last Name</label>
					<input type="text" class="form-control" name="abusedPerson.lastName"  placeholder="Last Name">
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label">Street Address</label>
					<input type="text" class="form-control" name="abusedPerson.streetAddress" placeholder="Street Address">
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-3">
				<div class="form-group no-margin-hr">
					<label class="control-label">City</label>
					<input type="text" class="form-control" name="abusedPerson.city"  placeholder="City">
				</div>
			</div>
			<div class="col-sm-3">
				<div class="form-group no-margin-hr">
					<label class="control-label">State/Province</label>
					<input type="text" class="form-control" name="abusedPerson.state"  placeholder="State/Province">
				</div>
			</div>
			<div class="col-sm-3">
				<div class="form-group no-margin-hr">
					<label class="control-label">Zip/Postal Code</label>
					<input type="text" class="form-control" name="abusedPerson.zip" placeholder="Zip/Postal Code">
				</div>
			</div>
			<div class="col-sm-3">
				<div class="form-group no-margin-hr">
					<label class="control-label">Country</label>
					<%= HtmlComponentUtil.getSelect("abusedPersonCountry", "abusedPerson.country", (List<SelectOption>)request.getAttribute("countryDatas"), null, "choose country...") %>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-6">
				<div class="form-group no-margin-hr">
					<label class="control-label">Phone Number</label>
					<input type="text" class="form-control" name="abusedPerson.telephone" placeholder="Phone Number">
				</div>
			</div>
			<div class="col-sm-6">
				<div class="form-group no-margin-hr">
					<label class="control-label">Email Address</label>
					<input type="text" class="form-control" name="abusedPerson.email" placeholder="Email Address">
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-6">
				<div class="form-group no-margin-hr">
					<label class="control-label">Birth Date of Abused</label>
					<div class="input-group date bs-datepicker-component">
						<input type="text" class="form-control" name="abusedPerson.birthDay"><span class="input-group-addon"><i class="fa fa-calendar"></i></span>
					</div>
				</div>
			</div>
			<div class="col-sm-6">
				<div class="form-group no-margin-hr">
					<label class="control-label">Or approx. Age</label>
					<select class="form-control unRender" name="abusedPerson.age">
						<c:forEach var="item" varStatus="status" begin="1" end="150">
						  	<option value="${item }">${item }</option>
						</c:forEach>
					</select>
					
				</div>
			</div>
		</div>
	
		<div class="row">
				<div class="col-sm-12">
					<div class="form-group no-margin-hr">
						<label class="control-label">Approximate Date Abuse Occurred</label>
						<div class="input-daterange input-group" id="bs-datepicker-range">
							<input type="text" class="input-sm form-control" name="caseStart" placeholder="Start date">
							<span class="input-group-addon">to</span>
							<input type="text" class="input-sm form-control" name="caseEnd" placeholder="End date">
						</div>
					</div>
				</div>
			</div>
		<hr>
			
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label"><h1 class="form-header">Information on the Person Reporting the Abuse(if different than above):</h1></label>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-6">
				<div class="form-group no-margin-hr">
					<label class="control-label">Relation to the Abused Person</label>
					<%= HtmlComponentUtil.getSelect("reportedByRelation", "reportedBy.relation", (List<SelectOption>)request.getAttribute("relations"), null, "Select a relation") %>
				</div>
			</div>
			<div class="col-sm-6">
				<div class="form-group no-margin-hr">
					<label class="control-label">If other, please explain</label>
					<input type="text" disabled="disabled" id="reportedByRelationOther" class="form-control" name="reportedBy.relationOther">
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-4">
				<div class="form-group no-margin-hr">
					<label class="control-label">First Name</label>
					<input type="text" class="form-control" name="reportedBy.firstName" placeholder="First Name">
				</div>
			</div>
			<div class="col-sm-4">
				<div class="form-group no-margin-hr">
					<label class="control-label">Middle Name</label>
					<input type="text" class="form-control" name="reportedBy.middleName" placeholder="Middle Name">
				</div>
			</div>
			<div class="col-sm-4">
				<div class="form-group no-margin-hr">
					<label class="control-label">Last Name</label>
					<input type="text" class="form-control" name="reportedBy.lastName" placeholder="Last Name">
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label">Street Address</label>
					<input type="text" class="form-control" id="jq-validation-username" name="reportedBy.streetAddress" placeholder="Street Address">
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-3">
				<div class="form-group no-margin-hr">
					<label class="control-label">City</label>
					<input type="text" class="form-control" name="reportedBy.city" placeholder="City">
				</div>
			</div>
			<div class="col-sm-3">
				<div class="form-group no-margin-hr">
					<label class="control-label">State/Province</label>
					<input type="text" class="form-control" name="reportedBy.state" placeholder="State/Province">
				</div>
			</div>
			<div class="col-sm-3">
				<div class="form-group no-margin-hr">
					<label class="control-label">Zip/Postal Code</label>
					<input type="text" class="form-control" name="reportedBy.zip" placeholder="Zip/Postal Code">
				</div>
			</div>
			<div class="col-sm-3">
				<div class="form-group no-margin-hr">
					<label class="control-label">Country</label>
					<%= HtmlComponentUtil.getSelect("reportCountry", "reportedBy.country", (List<SelectOption>)request.getAttribute("countryDatas"), null, "choose country...") %>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-6">
				<div class="form-group no-margin-hr">
					<label class="control-label">Phone Number</label>
					<input type="text" class="form-control" name="reportedBy.telephone" placeholder="Phone Number">
				</div>
			</div>
			<div class="col-sm-6">
				<div class="form-group no-margin-hr">
					<label class="control-label">Email Address</label>
					<input type="text" class="form-control" name="reportedBy.email" placeholder="Email Address">
				</div>
			</div>
		</div>
		<hr>
		
		<%
			List<AbuseType> abuseTypes = (List<AbuseType>)request.getAttribute("abuseTypes");
			if(abuseTypes != null)
			{
				for(int i=0; i<abuseTypes.size(); i++)
				{
					if(i%4 == 0)
					{
		%>
					<div class="row">
						<div class="col-sm-3">
							<div class="form-group no-margin-hr">
								<label class="control-label"><%=(i == 0 ? "Type of Abuse That Occurred(Check as many as apply)" : "") %></label>					
							</div>
						</div>
		<%
					}
		%>
						<div class="col-sm-2">
							<div class="form-group no-margin-hr">
								<label class="checkbox-inline">
									<input type="checkbox" class="px" value="<%=abuseTypes.get(i).getId() %>" name="abusetypeCheckbox"> <span class="lbl"><%=abuseTypes.get(i).getName() %></span>
								</label>			
							</div>
						</div>
		<%						
					if(i%4 == 3)
					{
		%>
					</div>
		<%				
					}
				}
			}
		%>
		<hr>
		<div class="row">
			<div class="col-sm-3">
				<div class="form-group no-margin-hr">
					<label class="control-label">Summary of Abuse That Occurred</label>				
				</div>
			</div>
			<div class="col-sm-9">
				<div class="form-group no-margin-hr">
					<textarea rows="3" class="form-control" name="summary"  placeholder="500 characters max"></textarea>
				</div>
			</div>
		</div>
		<hr>
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label"><h1 class="form-header" style="margin-bottom:10px; margin-top:10px">
					Mental Health Facilities Were Involved With the Abuse:
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label"><h1 class="form-header" style="margin-bottom:10px; margin-top:10px">Facilities Where the Abuse Occurred</h1></label>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-6">
				<div class="row">
					<div class="col-sm-5">
						<div class="form-group no-margin-hr">
							<label class="control-label">#1 - Facility Type</label>
						</div>
					</div>
					<div class="col-sm-7">
						<div class="form-group no-margin-hr">
							<%= HtmlComponentUtil.getSelect("facilityInfosType1", "facilityInfos[0].type", (List<SelectOption>)request.getAttribute("facilityTypes"), null, "Select an option") %>
						</div>
					</div>
					<div class="col-sm-5">
						<div class="form-group no-margin-hr">
							<label class="control-label">If other, please explain</label>
						</div>
					</div>
					<div class="col-sm-7">
						<div class="form-group no-margin-hr">
							<input type="text" disabled="disabled" id="facilityInfosTypeOther1" class="form-control" name="facilityInfos[0].typeOther">
						</div>
					</div>
					<div class="col-sm-5">
						<div class="form-group no-margin-hr">
							<label class="control-label">Facility Name</label>
						</div>
					</div>
					<div class="col-sm-7">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="facilityInfos[0].name" placeholder="Facility Name">
						</div>
					</div>
				</div>
				<div class="row">
					<div class="col-sm-5">
						<div class="form-group no-margin-hr">
							<label class="control-label">Street Address</label>
						</div>
					</div>
					<div class="col-sm-7">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="facilityInfos[0].streetAddress" placeholder="Street Address">
						</div>
					</div>
				</div>
				<div class="row">
					<div class="col-sm-1">
						<div class="form-group no-margin-hr">
							<label class="control-label">City</label>
						</div>
					</div>
					<div class="col-sm-4">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="facilityInfos[0].city" placeholder="City">
						</div>
					</div>
					<div class="col-sm-3">
						<div class="form-group no-margin-hr">
							<label class="control-label">State/Province</label>
						</div>
					</div>
					<div class="col-sm-4">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="facilityInfos[0].state" placeholder="State/Province">
						</div>
					</div>
				</div>
				<div class="row">
					<div class="col-sm-2">
						<div class="form-group no-margin-hr">
							<label class="control-label">Zip/Postal Code</label>
						</div>
					</div>
					<div class="col-sm-4">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="facilityInfos[0].zip" placeholder="Zip/Postal Code">
						</div>
					</div>
					<div class="col-sm-2">
						<div class="form-group no-margin-hr">
							<label class="control-label">Country</label>
						</div>
					</div>
					<div class="col-sm-4">
						<div class="form-group no-margin-hr">
							<%= HtmlComponentUtil.getSelect("facilitiesCountry1", "facilityInfos[0].country", (List<SelectOption>)request.getAttribute("countryDatas"), null, "choose country...") %>
						</div>
					</div>
				</div>
				<div class="row">
					<div class="col-sm-5">
						<div class="form-group no-margin-hr">
							<label class="control-label">Phone Number</label>
						</div>
					</div>
					<div class="col-sm-7">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="facilityInfos[0].telephone" placeholder="Phone Number">
						</div>
					</div>
				</div>
			</div>
			<div class="col-sm-6">
				<div class="row">
					<div class="col-sm-5">
						<div class="form-group no-margin-hr">
							<label class="control-label">#2 - Facility Type</label>
						</div>
					</div>
					<div class="col-sm-7">
						<div class="form-group no-margin-hr">
							<%= HtmlComponentUtil.getSelect("facilityInfosType2", "facilityInfos[1].type", (List<SelectOption>)request.getAttribute("facilityTypes"), null, "Select an option") %>
						</div>
					</div>
					<div class="col-sm-5">
						<div class="form-group no-margin-hr">
							<label class="control-label">If other, please explain</label>
						</div>
					</div>
					<div class="col-sm-7">
						<div class="form-group no-margin-hr">
							<input type="text" disabled="disabled" id="facilityInfosTypeOther2" class="form-control" name="facilityInfos[1].typeOther">
						</div>
					</div>
					<div class="col-sm-5">
						<div class="form-group no-margin-hr">
							<label class="control-label">Facility Name</label>
						</div>
					</div>
					<div class="col-sm-7">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="facilityInfos[1].name" placeholder="Facility Name">
						</div>
					</div>
				</div>
				<div class="row">
					<div class="col-sm-5">
						<div class="form-group no-margin-hr">
							<label class="control-label">Street Address</label>
						</div>
					</div>
					<div class="col-sm-7">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="facilityInfos[1].streetAddress" placeholder="Street Address">
						</div>
					</div>
				</div>
				<div class="row">
					<div class="col-sm-1">
						<div class="form-group no-margin-hr">
							<label class="control-label">City</label>
						</div>
					</div>
					<div class="col-sm-4">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="facilityInfos[1].city" placeholder="City">
						</div>
					</div>
					<div class="col-sm-3">
						<div class="form-group no-margin-hr">
							<label class="control-label">State/Province</label>
						</div>
					</div>
					<div class="col-sm-4">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="facilityInfos[1].state" placeholder="State/Province">
						</div>
					</div>
				</div>
				<div class="row">
					<div class="col-sm-2">
						<div class="form-group no-margin-hr">
							<label class="control-label">Zip/Postal Code</label>
						</div>
					</div>
					<div class="col-sm-4">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="facilityInfos[1].zip" placeholder="Zip/Postal Code">
						</div>
					</div>
					<div class="col-sm-2">
						<div class="form-group no-margin-hr">
							<label class="control-label">Country</label>
						</div>
					</div>
					<div class="col-sm-4">
						<div class="form-group no-margin-hr">
							<%= HtmlComponentUtil.getSelect("facilitiesCountry2", "facilityInfos[1].country", (List<SelectOption>)request.getAttribute("countryDatas"), null, "choose country...") %>
						</div>
					</div>
				</div>
				<div class="row">
					<div class="col-sm-5">
						<div class="form-group no-margin-hr">
							<label class="control-label">Phone Number</label>
						</div>
					</div>
					<div class="col-sm-7">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="facilityInfos[1].telephone" placeholder="Phone Number">
						</div>
					</div>
				</div>
			</div>
		</div>
		<hr>
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label"><h1 class="form-header" style="margin-bottom:10px; margin-top:10px">Doctors Were Involved With the Abuse:</h1></label>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label"><h1 class="form-header" style="margin-bottom:10px; margin-top:10px">Doctors Who Were Involved With the Abuse</h1></label>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-6">
				<div class="row">
					<div class="col-sm-5">
						<div class="form-group no-margin-hr">
							<label class="control-label">#1 - Doctor First Name</label>
						</div>
					</div>
					<div class="col-sm-7">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="doctorInfos[0].name" placeholder="Doctor First Name">
						</div>
					</div>
				</div>
				<div class="row">
					<div class="col-sm-5">
						<div class="form-group no-margin-hr">
							<label class="control-label">#1 - Doctor Type</label>
						</div>
					</div>
					<div class="col-sm-7">
						<div class="form-group no-margin-hr">
							<%= HtmlComponentUtil.getSelect("doctorInfos1", "doctorInfos[0].docType", (List<SelectOption>)request.getAttribute("docTypes"), null, "choose a doctor type...") %>
						</div>
					</div>
				</div>
				<div class="row">
					<div class="col-sm-5">
						<div class="form-group no-margin-hr">
							<label class="control-label">Street Address</label>
						</div>
					</div>
					<div class="col-sm-7">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="doctorInfos[0].streetAddress" placeholder="Street Address">
						</div>
					</div>
				</div>
				<div class="row">
					<div class="col-sm-1">
						<div class="form-group no-margin-hr">
							<label class="control-label">City</label>
						</div>
					</div>
					<div class="col-sm-4">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="doctorInfos[0].city" placeholder="City">
						</div>
					</div>
					<div class="col-sm-3">
						<div class="form-group no-margin-hr">
							<label class="control-label">State/Province</label>
						</div>
					</div>
					<div class="col-sm-4">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="doctorInfos[0].state" placeholder="State/Province">
						</div>
					</div>
				</div>
				<div class="row">
					<div class="col-sm-2">
						<div class="form-group no-margin-hr">
							<label class="control-label">Zip/Postal Code</label>
						</div>
					</div>
					<div class="col-sm-4">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="doctorInfos[0].zip" placeholder="Zip/Postal Code">
						</div>
					</div>
					<div class="col-sm-2">
						<div class="form-group no-margin-hr">
							<label class="control-label">Country</label>
						</div>
					</div>
					<div class="col-sm-4">
						<div class="form-group no-margin-hr">
							<%= HtmlComponentUtil.getSelect("doctorCountry1", "doctorInfos[0].country", (List<SelectOption>)request.getAttribute("countryDatas"), null, "choose country...") %>
						</div>
					</div>
				</div>
				<div class="row">
					<div class="col-sm-5">
						<div class="form-group no-margin-hr">
							<label class="control-label">Phone Number</label>
						</div>
					</div>
					<div class="col-sm-7">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="doctorInfos[0].telephone" placeholder="Phone Number">
						</div>
					</div>
				</div>
			</div>
			<div class="col-sm-6">
				<div class="row">
					<div class="col-sm-5">
						<div class="form-group no-margin-hr">
							<label class="control-label">#2 - Doctor First Name</label>
						</div>
					</div>
					<div class="col-sm-7">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="doctorInfos[1].name" placeholder="Doctor First Name">
						</div>
					</div>
				</div>
				<div class="row">
					<div class="col-sm-5">
						<div class="form-group no-margin-hr">
							<label class="control-label">#2 - Doctor Type</label>
						</div>
					</div>
					<div class="col-sm-7">
						<div class="form-group no-margin-hr">
							<%= HtmlComponentUtil.getSelect("doctorInfos2", "doctorInfos[1].docType", (List<SelectOption>)request.getAttribute("docTypes"), null, "choose a doctor type...") %>
						</div>
					</div>
				</div>
				<div class="row">
					<div class="col-sm-5">
						<div class="form-group no-margin-hr">
							<label class="control-label">Street Address</label>
						</div>
					</div>
					<div class="col-sm-7">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="doctorInfos[1].streetAddress" placeholder="Street Address">
						</div>
					</div>
				</div>
				<div class="row">
					<div class="col-sm-1">
						<div class="form-group no-margin-hr">
							<label class="control-label">City</label>
						</div>
					</div>
					<div class="col-sm-4">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="doctorInfos[1].city" placeholder="City">
						</div>
					</div>
					<div class="col-sm-3">
						<div class="form-group no-margin-hr">
							<label class="control-label">State/Province</label>
						</div>
					</div>
					<div class="col-sm-4">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="doctorInfos[1].state" placeholder="State/Province">
						</div>
					</div>
				</div>
				<div class="row">
					<div class="col-sm-2">
						<div class="form-group no-margin-hr">
							<label class="control-label">Zip/Postal Code</label>
						</div>
					</div>
					<div class="col-sm-4">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="doctorInfos[1].zip" placeholder="Zip/Postal Code">
						</div>
					</div>
					<div class="col-sm-2">
						<div class="form-group no-margin-hr">
							<label class="control-label">Country</label>
						</div>
					</div>
					<div class="col-sm-4">
						<div class="form-group no-margin-hr">
							<%= HtmlComponentUtil.getSelect("doctorCountry2", "doctorInfos[1].country", (List<SelectOption>)request.getAttribute("countryDatas"), null, "choose country...") %>
						</div>
					</div>
				</div>
				<div class="row">
					<div class="col-sm-5">
						<div class="form-group no-margin-hr">
							<label class="control-label">Phone Number</label>
						</div>
					</div>
					<div class="col-sm-7">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="doctorInfos[1].telephone" placeholder="Phone Number">
						</div>
					</div>
				</div>
			</div>
		</div>
		<hr>
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label"><h1 class="form-header" style="margin-bottom:10px; margin-top:10px">Were Psychiatric Drugs Prescribed?</h1></label>
					<select name="drugsPrescribed" class="unRender">
						<option value="No">No</option>
						<option value="Yes">Yes</option>
					</select>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label"><h1 class="form-header" style="margin-bottom:10px; margin-top:10px">What Psychiatric Drugs Were Prescribed?</h1></label>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-1">
				<div class="form-group no-margin-hr">
					<label class="control-label">#1</label>		
						
				</div>
			</div>
			<div class="col-sm-3">
				<div class="form-group no-margin-hr">
					<%= HtmlComponentUtil.getSelect("id_1", "drugIds", (List<SelectOption>)request.getAttribute("datas"), null, "Select an option") %>
				</div>
			</div>
			<div class="col-sm-1">
				<div class="form-group no-margin-hr">
					<label class="control-label">#2</label>				
				</div>
			</div>
			<div class="col-sm-3">
				<div class="form-group no-margin-hr">
					<%= HtmlComponentUtil.getSelect("id_2", "drugIds", (List<SelectOption>)request.getAttribute("datas"), null, "Select an option") %>
				</div>
			</div>
			<div class="col-sm-1">
				<div class="form-group no-margin-hr">
					<label class="control-label">#3</label>				
				</div>
			</div>
			<div class="col-sm-3">
				<div class="form-group no-margin-hr">
					<%= HtmlComponentUtil.getSelect("id_3", "drugIds", (List<SelectOption>)request.getAttribute("datas"), null, "Select an option") %>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-1">
				<div class="form-group no-margin-hr">
					<label class="control-label">#4</label>				
				</div>
			</div>
			<div class="col-sm-3">
				<div class="form-group no-margin-hr" >
					<%= HtmlComponentUtil.getSelect("id_4", "drugIds", (List<SelectOption>)request.getAttribute("datas"), null, "Select an option") %>
				</div>
			</div>
			<div class="col-sm-1">
				<div class="form-group no-margin-hr">
					<label class="control-label">#5</label>				
				</div>
			</div>
			<div class="col-sm-3">
				<div class="form-group no-margin-hr">
					<%= HtmlComponentUtil.getSelect("id_5", "drugIds", (List<SelectOption>)request.getAttribute("datas"), null, "Select an option") %>
				</div>
			</div>
			<div class="col-sm-1">
				<div class="form-group no-margin-hr">
					<label class="control-label">#6</label>				
				</div>
			</div>
			<div class="col-sm-3">
				<div class="form-group no-margin-hr">
					<%= HtmlComponentUtil.getSelect("id_6", "drugIds", (List<SelectOption>)request.getAttribute("datas"), null, "Select an option") %>
				</div>
			</div>
		</div>
		<hr>
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label"><h1 class="form-header" style="margin-bottom:10px; margin-top:10px">Are You Working With an Attorney?</h1></label>
					<select class="unRender" name="attorney.workWithAttorney" id="attorneyWorkWithAttorney">
						<option value="Yes">Yes</option>
						<option value="No">No</option>
					</select>
				</div>
			</div>
		</div>
		<div class="row attorney-form">
			<div class="form-group no-margin-hr">
				<label class="col-sm-2 control-label">Attorney Name</label>
				<div class="col-sm-10">
					<input type="text" class="form-control" name="attorney.name" placeholder="Attorney Name">
				</div>
			</div>
			<div class="form-group no-margin-hr">
				<label class="col-sm-2 control-label">Street Address</label>
				<div class="col-sm-4">
					<input type="text" class="form-control" name="attorney.streetAddress" placeholder="Street Address">
				</div>
				<label class="col-sm-2 control-label">City</label>
				<div class="col-sm-4">
					<input type="text" class="form-control" name="attorney.city" placeholder="City">
				</div>
			</div>
			<div class="form-group no-margin-hr">
				<label class="col-sm-2 control-label">State/Province</label>
				<div class="col-sm-4">
					<input type="text" class="form-control" name="attorney.state" placeholder="State/Province">
				</div>
				<label class="col-sm-2 control-label">Zip/Postal Code</label>	
				<div class="col-sm-4">
					<input type="text" class="form-control" name="attorney.zip" placeholder="Zip/Postal Code">
				</div>
			</div>
			<div class="form-group no-margin-hr">
				<label class="col-sm-2 control-label">Country</label>
				<div class="col-sm-2">
					<%= HtmlComponentUtil.getSelect("attorneyCountry", "attorney.country", (List<SelectOption>)request.getAttribute("countryDatas"), null, "choose country...") %>
				</div>
				<label class="col-sm-2 control-label">Phone Number</label>
				<div class="col-sm-2">
					<input type="text"  class="form-control" name="attorney.telephone" placeholder="Phone Number">
				</div>
				<label class="col-sm-2 control-label">Email Address</label>
				<div class="col-sm-2">
					<input type="text" class="form-control" name="attorney.email" placeholder="Email Address">
				</div>
			</div>
		</div>
		<div class="row">
			<div class="form-group no-margin-hr">
				<label class="col-sm-7 control-label">Would like assistance in getting an attorney to file charges or represent your case.</label>
				<div class="col-sm-1">
					<input type="checkbox" class="form-control" value="1"  name="attorney.assistanceAttorney">
				</div>
			</div>
		</div>
		<hr>
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label"><h1 class="form-header" style="margin-bottom:10px; margin-top:10px">What Actions Are You Interested in Taking On This Case?</h1></label>
				</div>
			</div>
		</div>
		<%
			List<Action> actions = (List<Action>)request.getAttribute("actions");
			if(actions != null)
			{
				for(Action action : actions)
				{
		%>
			<div class="row">
				<div class="col-sm-12">
					<div class="form-group no-margin-hr">
						<label class="checkbox-inline">
							<input type="checkbox" class="px" value="<%=action.getId() %>" name="actionsCheckbox"> <span class="lbl"><%=action.getName() %></span>
						</label>			
					</div>
				</div>
			</div>
		<%
				}
			}
		%>
		
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="checkbox-inline">
						<input type="checkbox" class="px" id="otherActionCheck" > <span class="lbl"><input type="text" id="otherActionInput" disabled="disabled" class="form-control" name="otherAction" placeholder="Other"></span>
					</label>			
				</div>
			</div>
		</div>
		
		<hr>
			<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label"><h1 class="form-header" style="margin-bottom:10px; margin-top:10px">Preferred Contact</h1></label>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-6">
				<div class="form-group no-margin-hr">
					<label class="control-label">Best Time to Contact</label>
					<input type="text" class="form-control" placeholder="Best Time">
				</div>
			</div>
			<div class="col-sm-6">
				<div class="form-group no-margin-hr">
					<label class="control-label">Best way to contact</label>
					<input type="text" class="form-control" placeholder="Best Way">
				</div>
			</div>
		</div>
		<br>
		<div class="form-actions">
			<input type="submit" value="Submit" class="btn btn-primary btn-lg btn-block">
		</div>
		<hr>
		<a href="https://www.cchrint.org/">
			<img src="<%=contextPath%>/assets/images/case/create_footer.png"/>
		</a>
		</form>



	
	<!-- / Form -->

<!-- Get jQuery from Google CDN -->
<!--[if !IE]> -->
	<script type="text/javascript"> window.jQuery || document.write('<script src="<%=contextPath%>/assets/javascripts/jquery-2.0.3.min.js">'+"<"+"/script>"); </script>
<!-- <![endif]-->
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	<script type="text/javascript"> window.jQuery || document.write('<script src="<%=contextPath%>/assets/javascripts/jquery-1.8.3.min.js">'+"<"+"/script>"); </script>
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<!-- Pixel Admin's javascripts -->
<script src="<%=contextPath%>/assets/javascripts/bootstrap.min.js"></script>
<script src="<%=contextPath%>/assets/javascripts/pixel-admin.min.js"></script>
<script src="<%=contextPath%>/assets/javascripts/select2.min.js"></script>

<script type="text/javascript">
	window.PixelAdmin.start([
		function () {
			$("#signup-form_id").validate({ focusInvalid: true, errorPlacement: function () {} });

			
		}
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</script>

<!-- Javascript -->
	<script>var init = [];</script>
	<script>
    
		init.push(function () {

			$('.bs-datepicker-component').datepicker();
			
			var options2 = {
				orientation: $('body').hasClass('right-to-left') ? "auto right" : 'auto auto'
			}
			$('#bs-datepicker-range').datepicker(options2);
			
			$("select:not(.unRender)").select2({
			    allowClear: true
			});

			$('#otherActionCheck').click(function(){
				if($('#otherActionCheck')[0].checked)
				{
					$('#otherActionInput').attr('disabled', false);
				}
				else
				{
					$('#otherActionInput').attr('disabled', true);
					$('#otherActionInput').val('');
				}
			});

			$('#reportedByRelation').change(function(){
				if($(this).val() == 'Other')
				{
					$('#reportedByRelationOther').attr('disabled', false);
				}
				else
				{
					$('#reportedByRelationOther').attr('disabled', true);
					$('#reportedByRelationOther').val('');
				}
			});

			$('#facilityInfosType1').change(function(){
				if($(this).val() == 'Other')
				{
					$('#facilityInfosTypeOther1').attr('disabled', false);
				}
				else
				{
					$('#facilityInfosTypeOther1').attr('disabled', true);
					$('#facilityInfosTypeOther1').val('');
				}
			});

			$('#facilityInfosType2').change(function(){
				if($(this).val() == 'Other')
				{
					$('#facilityInfosTypeOther2').attr('disabled', false);
				}
				else
				{
					$('#facilityInfosTypeOther2').attr('disabled', true);
					$('#facilityInfosTypeOther2').val('');
				}
			});
			
			$('#attorneyWorkWithAttorney').change(function(){
				if($(this).val() == 'No')
				{
					$('.attorney-form').hide();
				}
				else
				{
					$('.attorney-form').show();
				}
			});
			
			$("#jq-validation-form").validate({
				ignore: '.ignore',
				focusInvalid: true,
				rules: {
					'abusedPerson.firstName': {
						required: true
					},
					'abusedPerson.city': {
						required: true
					},
					'abusedPerson.telephone': {
						required: true
					},
					'abusedPerson.email': {
					  required: true,
					  email: true
					},
				}
			});
			
		});
		window.PixelAdmin.start(init);
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</body>
</html>
